Normal Gait Smooth, rhythmic, efficient Gait cycle consists of one stride by each leg In normal walking, one foot is always on ground

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2 Normal Gait Smooth, rhythmic, efficient Gait cycle consists of one stride by each leg In normal walking, one foot is always on ground (running both feet leave ground)

3 Gait Cycle

4 Maturation of Gait Small child has a faster cadence, but a slower velocity, cannot take longer steps to increase speed Young children walk with hips, knees, and ankles more flexed and feet more widely spread, externally rotated This lowers center of gravity, making balance easier, gives wider base of support Children cannot stand on one foot for one second until age of three years old Mature walking patterns exhibited by age three years old

5 Types of Limp Antalgic Gait: Painful gait, shorter amount of time on painful limb Stiff-legged Gait: Knee pain, circumducts leg Slap-Foot or Steppage Gait: See with drop-foot, increased knee and hip extension in swing phase, cannot control foot deceleration (therefore it slaps) Spastic Gait: Toe walking Tibial torsion Crouch Gait: Tight hip flexors (CP, Spine problems) Antalgic Gait

6 Types of Limp Antalgic Gait: Painful gait, shorter amount of time on painful limb Stiff-legged Gait: Knee pain, circumducts leg Slap-Foot or Steppage Gait: See with drop-foot, increased knee and hip extension in swing phase, cannot control foot deceleration (therefore it slaps) Spastic Gait: Toe walking Tibial torsion Crouch Gait: Tight hip flexors (CP, Spine problems) Stiff-legged Gait

7 Types of Limp Antalgic Gait: Painful gait, shorter amount of time on painful limb Stiff-legged Gait: Knee pain, circumducts leg Slap-Foot or Steppage Gait: See with drop-foot, increased knee and hip extension in swing phase, cannot control foot deceleration (therefore it slaps) Spastic Gait: Toe walking Tibial torsion Crouch Gait: Tight hip flexors (CP, Spine problems) Stiff-legged Gait

8 Types of Limp Antalgic Gait: Painful gait, shorter amount of time on painful limb Stiff-legged Gait: Knee pain, circumducts leg Slap-Foot or Steppage Gait: See with drop-foot, increased knee and hip extension in swing phase, cannot control foot deceleration (therefore it slaps) Spastic Gait: Toe walking Tibial torsion Crouch Gait: Tight hip flexors (CP, Spine problems) Slap-Foot or Steppage Gait

9 Types of Limp Antalgic Gait: Painful gait, shorter amount of time on painful limb Stiff-legged Gait: Knee pain, circumducts leg Slap-Foot or Steppage Gait: See with drop-foot, increased knee and hip extension in swing phase, cannot control foot deceleration (therefore it slaps) Spastic Gait: Toe walking Tibial torsion Crouch Gait: Tight hip flexors (CP, Spine problems) Slap-Foot or Steppage Gait

10 Types of Limp Antalgic Gait: Painful gait, shorter amount of time on painful limb Stiff-legged Gait: Knee pain, circumducts leg Slap-Foot or Steppage Gait: See with drop-foot, increased knee and hip extension in swing phase, cannot control foot deceleration (therefore it slaps) Spastic Gait: Toe walking Tibial torsion Crouch Gait: Tight hip flexors (CP, Spine problems) Crouch Gait

11 Types of Limp Ataxia: Spinal/cerebellar disease Trendelenburg Gait: Head/trunk are shifted over affected limb during single stance phase of affected limb. Reduces joint reaction force Gluteus Maximus Limp: Patient hyper extends the trunk and pelvis to keep center of gravity behind hip joint. Proximal weakness conditions: Duchenne s muscular dystrophy spinal muscular atrophy Back Knee Gait: Ankle contracture Trendelenburg Gait

12 Types of Limp Ataxia: Spinal/cerebellar disease Trendelenburg Gait: Head/trunk are shifted over affected limb during single stance phase of affected limb. Reduces joint reaction force Gluteus Maximus Limp: Patient hyper extends the trunk and pelvis to keep center of gravity behind hip joint. Proximal weakness conditions: Duchenne s muscular dystrophy spinal muscular atrophy Back Knee Gait: Ankle contracture Gluteus Maximus Limp

13 History Episode of trauma may be misleading Limp intermittent, early in morning, at the end of the day Young child may refuse to stand/walk Delayed motor milestones Deterioration of ability

14 Referred Pain Back pathology can be present with hip pain Knee or thigh pain may indicate hip pathology

15 Trauma Walks on toes (heel or tibia) Walks on heels (forefoot)

16 Trauma Mechanism Child going down slide (TIBIA) Jumping from height (CALCANEUS or FOREFOOT) Parent fall, holding child (FEMUR or TIBIA)

17 Septic Joint Febrile Child appears ill Elevated WBC, ESR, C-reactive protein Blood culture positive 50% of the time Trauma can precede infection X-ray, bone scan, MRI, aspiration Can start with osteomyelitis which extends into joint Pus is chondrolytic Severe pain

18 Kocher Criteria Febrile ESR > 40 WBC > 12,000 NWB on affected side SCORE SEPTIC ARTHRITIS 1 3% 2 40% 3 93% 4 99%

19 Evolution of Staphylococcus Fewer septic joints More myositis MRI preferred imaging

20 Anatomy- Anterior Approach to Hip

21 Transient Synovitis Diagnosis of exclusion Usually involves the hip Viral infection, allergic reaction (prodromal illness) ESR greater than 20, WBC normal Do not appear very sick Wakes up after nap or in the AM with limp or refusing to bear weight Eating, Watching TV, playing Low grade temperature

22 Transient Synovitis Treatment: Rest NSAID s--- scheduled Motrin or Ibuprofen for 5-7 days!! Check patient in a few days to ensure improvement

23 Juvenile Rheumatoid Arthritis (JRA) Rash is salmon colored with central clearing (different than Lyme) Systemic (20%) Polyarticular (50%) Pauciarticular (30%) Girls greater than boys Knee most commonly involved (66%) Ankle (25%) Hand/wrist (33%) Hip and c-spine (3%) Painful effusion, morning pain Elevated ESR, can have normal labs

24 Leukemia Antalgic gait Pain of variable intensity/duration Irritable hip/knee Lab abnormalities Organomegaly Lymphadenopathy

25 Legge-Calve-Perthes Disease Groin, hip, knee, thigh pain Vascular insult leads to osteonecrosis of the proximal femoral epiphysis Young white male, hyperactive, small for age Decreased hip range of motion X-rays, bone scan, MRI

26 Legge-Calve-Perthes Disease Groin, hip, knee, thigh pain Vascular insult leads to osteonecrosis of the proximal femoral epiphysis Young white male, hyperactive, small for age Decreased hip range of motion X-rays, bone scan, MRI

27 Legge-Calve-Perthes Disease Groin, hip, knee, thigh pain Vascular insult leads to osteonecrosis of the proximal femoral epiphysis Young white male, hyperactive, small for age Decreased hip range of motion X-rays, bone scan, MRI

28 Legge-Calve-Perthes Disease Treatment: Symptomatic Therapy Bracing Casts Surgery

29 Toe Walking CP, idiopathic, muscular dystrophy Should not persist after age 3? Unilateral Big calves Spasticity/clonus

30 Gower s Maneuver

31 Slipped Capital Femoral Epiphysis Weakness at zone of hypertrophy in physis Puberty, renal disease, hyperthyroidism Obese black adolescent male Externally rotated gait Hip / knee pain

32 Slipped Capital Femoral Epiphysis Stable: Patient is able to weight bear No Osteonecrosis

33 Slipped Capital Femoral Epiphysis Unstable: Patient is unable to weight bear due to severe pain 50% develop Osteonecrosis

34 Slipped Capital Femoral Epiphysis Treatment: Surgery pinning in situ reduction before pinning is controversial

35 Slipped Capital Femoral Epiphysis

36 Slipped Capital Femoral Epiphysis

37 Limb Length Discrepancy Painless limp Unilateral toe walking Can cause apparent scoliosis Fibular hemimelia Congenital short femur Proximal femoral focal deficiency (PFFD) DDH Hemihypertrophy Trauma

38 Limb Length Discrepancy

39 Limb Length Discrepancy Treatment: Less than 2 cm., shoe lifts Greater than 2 cm., surgery

40 Lyme Disease Positive Lyme titer, elevated ESR, CRP Knee: painless effusion Spirochete (Borrelia burgdorferi) Bull s eye rash Delayed onset

41 Foreign Body Check feet/knees for splinters X-ray, Ultrasound, CT scan

42 Tarsal Coalition Spastic peroneal flatfoot Presents 8-16 years old Limited subtalar motion Calcaneonavicular coalition is most common

43 Tarsal Coalition Treatment: Try period of immobilization Resect, interpose muscle or fat to prevent recurrence Consider fusion if morbidly obese, recurrent, or large talocalcaneal coalition

44 Cerebral Palsy Non-progressive neuromuscular disorder with onset prior to age 2 years old due to brain injury Results in mixture of muscle weakness/spasticity Hemiplegia, diplegia, complete involvement Toe walk, scissor gait, crouch gait Delayed motor milestones

45 Discitis Slow cautious gait Inflammatory lesion of disk space Back, abdominal pain Refuse to bear pain Probable bacterial etiology 30-50% positive blood culture rate

46 Discitis Treatment: IV antibiotics Follow labs Biopsy case which does not respond